WHO May Lose Credibility After Ebola

Agency seeks a new model after flaws revealed by Ebola crisis.

As the Ebola epidemic drags on, the World Health Organization is in danger of losing its credibility as a bulwark against infectious disease.

The West African epidemic is a "mega-crisis (that) overwhelmed the capacity of WHO," according to Director-General Margaret Chan, MD, speaking to reporters in late January.

To prevent a similar crisis in the future, Chan has proposed a package of reforms, including a large contingency fund for emergencies, an increase in the number of trained people able to deploy quickly to a crisis site, and structural changes to streamline the famously unwieldy organization.

Whether those get anywhere is the vital question, according to Lawrence Gostin, JD, of the O'Neill Institute for National and Global Health Law at Washington's Georgetown University.

And if the opportunity for reform is missed, Gostin said, "WHO will have lost the confidence of the world for a generation."

Gostin was a member of a reform advisory committee Chan set up early in her term in office, but none of the recommendations from that committee went anywhere, he said -- either watered down internally or not accepted by the member states.

Time for Reform?

But this time, Chan has said she thinks the member states -- which will meet as the World Health Assembly in May -- might be on her side.

"The member states truly, truly understand the world does need a collective defense mechanism for global health security," Chan told reporters. The evidence of that, she said, is that the organization's 34-member executive board unanimously approved a resolution -- put forward by the U.S. and South Africa -- seeking reforms.

"The WHO we have is not the WHO we need," said CDC Director Tom Frieden, MD, during the board discussion.

There is general consensus that the proposed reforms move in the right direction, according to experts reached by MedPage Today.

"This is the right thing for Margaret Chan to do," according to Ana Ayala, JD, also of Georgetown's O'Neill Institute, noting that similar reforms have been proposed before, most notably in the wake of the 2009-2010 influenza pandemic, and went nowhere.

But this time, perhaps, there will be enough pressure to get some changes made. "It would be in the best interests of the WHO, given that it has lost a great deal of credibility in the eyes of the international community," she told MedPage Today.

Magnifying Glass

"The WHO is currently under a magnifying glass," she added.

"People at the WHO really learned from the experience of Ebola and saw what happens when you are underprepared," commented Amesh Adalja, MD, of the Center for Health Security at the University of Pittsburgh Medical Center.

The epidemic started in December 2013, in a remote forested area of Guinea. But by the time anyone noticed, 3 months had passed and the virus had a grasp on the region that it has yet to relinquish.

Recent data suggest that the battle against the disease is slowly being won. The WHO figures for the week ending Feb. 8 show 144 newly confirmed cases in Guinea, Liberia, and Sierra Leone.

It's the second week in a row that incidence rose after several declines. But the totals remain relatively low compared with last year, when at times Liberia was reporting more than 360 cases a week and Sierra Leone saw more than 500.

But, Adalja said, the numbers are also a lot worse than they could have been -- had the world been prepared.

"If they had known 3 months earlier," he told MedPage Today, "they might have been able to forestall almost everything that has happened since."

The first problem was that Guinea -- like Liberia and Sierra Leone -- had an almost nonexistent public health system. Doctors were scarce, especially in the hinterland, and there was really no one to ring the alarm bells in time.

More intense efforts are needed to make sure that vulnerable states have better medical and epidemiological infrastructures, but that is likely to be a tough sell, Gostin said.

Building up local infrastructures is actually something WHO member states are obliged to do, both their own and those of less fortunate countries. But it's an "expensive and long-term proposition," Gostin said, and even in the latest reform proposals there's no plan for sustainable funding to do that.

In the Ebola outbreak, the WHO initially saw itself not as a player but as a sort of big brother, offering "technical assistance" to the local authorities. But, Adalja said, you can't give technical assistance when there's "no infrastructure to assist."

Lesson Learned?

To be fair, some of the WHO member states -- the U.S. among them -- appear to have learned that lesson. The U.S. administration has pledged to spend at least some of its Ebola-fighting fund on enhancing the capacity of vulnerable countries to prevent disease outbreaks.

Of course, Adalja added, one of the side effects of the outbreak is that some needed infrastructure is being built up in the three West African countries and presumably their capacity to deal with a future outbreak will be better.

Presumably, also, the WHO's own capacity to take action will be greater, if it gets its large emergency contingency fund and rapid response workforce of about 1,500 doctors and nurses.

"In the Ebola crisis," Ayala said, the agency did not have "the appropriate resources to send the necessary people." The reforms aimed at overcoming those gaps are on the table and appear to have widespread support.

But structural problems seem likely to continue and whether they can be ironed out will depend on the member states, when the World Health Assembly meets in May.

The problem has been, Gostin says, that the member states have not regarded themselves as "stakeholders" in the future of the agency and so have saddled it with an "unsustainable model" of organization.

"They've structured the organization in such a way that it's set up to fail," he said.

The agency only controls about a third of its annual budget -- the dues collected from the member states -- but has little or no say over the rest, money given by specific states or philanthropists and usually earmarked for specific projects. "No organization can operate effectively like that," he said.

It's infectious diseases -- Ebola, flu, SARS -- that get the headlines. For the public, Adalja said, "no other area has the same impact."

But the WHO doesn't just deal with infectious disease outbreaks -- a lot of its effort goes into other forms of ill health, including such things as noncommunicable diseases, tobacco, and obesity. When money and resources are tight, those areas get squeezed too.

Balkanized Agency

The agency has also been described as "seven WHOs, not one" -- the head office in Geneva and six regional health organizations that operate more or less as independent fiefdoms.

During the early days of the Ebola outbreak, Gostin notes, Geneva and the regional office for Africa (AFRO) were often at odds.

It seems likely that Chan will get her contingency fund -- indeed, the U.K. has already pledged $10 million for it. And she might also get her medical rapid response force of about 1,500 doctors, nurses, and other professionals.

But whether those and other needed reforms go ahead will depend on the political will expressed by Chan and the member states in May.

"Is Ebola a game-changer?" asked Gostin. "Will the director-general for the first time insist and not give up, and not yield to member states? And will member states act like stakeholders that want the WHO to succeed?"

"It will be absolutely the most important World Health Assembly in living memory."

And, he argued, if the assembly ends with a stronger, more effective WHO, the Ebola crisis will have become -- still a disaster, yes -- but also a "transformational moment" for international public health.

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